Overview & Frequently Asked Questions
Thank you for your interest in the UNC TMS Clinic! Please review our website to learn more about our clinic and TMS therapy to determine if we are a right fit for your psychiatric needs.
What is TMS?
Transcranial magnetic stimulation, or TMS, is a safe, effective, and noninvasive form of brain stimulation. Approved by the US Food and Drug Administration (FDA) in 2008, TMS devices operate outside of the body and use powerful magnetic fields to stimulate nerve cells in specific areas of the brain to improve symptoms of depression and anxiety. TMS therapy is indicated for individuals diagnosed with Major Depressive Disorder (MDD) who have not achieved satisfactory symptom improvement from antidepressant medications and therapy. TMS therapy is often used in individuals who are unable to tolerate side effects from antidepressant medications such as weight gain and sexual dysfunction; however, TMS can be used alone or in conjunction with medications. TMS does not require anesthesia and patients may resume daily activities right after treatment. The UNC Outpatient psychiatry clinic currently utilizes the MagVenture TMS device with therapeutic treatments provided by a psychiatrist and TMS coordinator. Although TMS has been studied for a number of psychiatric and neurologic conditions, at this time UNC TMS clinic treats individuals who suffer from severe and/or recurrent major depressive disorder.
What is a typical TMS series?
The initial course of treatment typically consists of 5 treatments per week over a 6-week period, with a TMS taper for 36 total treatments. Each treatment session lasts approximately 20-40 minutes. During treatment, the patient is awake in a comfortable chair. A small magnetized wand rests lightly on the patient’s head, delivering focused magnetic stimulation directly to the area of the brain thought to be involved in regulating mood. The location targeted is called the dorsolateral prefrontal cortex (DLPFC) and is located over the front of the brain, above the left eye, near where most people have a normal hairline. You can drive yourself to and from the clinic and do not need a driver. Many patients are able to go straight back to work or school. There is no need to worry about what to eat as TMS can be done on a full stomach. You will not be put to sleep (no anesthesia or even an IV), and you can take your medications all on your normal schedule.
What if I cannot come in daily?
Experts have studied TMS only with daily repeated sessions. We do not have data that TMS is effective or not if treatments are delivered with less frequent sessions. The clinicians at UNC are experienced with this technology and will work with you to optimize a schedule that best fits your clinical and personal needs.
What is involved in a TMS induction?
The first appointment is called the TMS “induction” which includes brain mapping, motor threshold determination, and initial treatment session. At this appointment the treating psychiatrist will begin by mapping out a region on your scalp which correlates to the dorsolateral prefrontal cortex (DLPFC). We will then test the minimum energy needed to stimulate your brain, also known as your resting motor threshold. This determines the dose of magnetic stimulation that you will need during the course of your treatment series. Motor threshold determination is performed by stimulating the left scalp over an area of the brain (pre-motor cortex) that controls your right hand. Stimulation with the TMS magnetic wand in this location will cause your hand to have a single muscle jerk or twitch. Once we have completed brain mapping and motor threshold determination, we will proceed with the initial treatment.
What is Theta Burst Stimulation?
Intermittent Theta burst stimulation (iTBS) protocol was approved for use on MagVenture TMS devices in August of 2018 and is a newer and faster form of TMS where the magnetic pulses are applied in a certain pattern, called bursts. Conventional TMS procedures typically last 20- 40 minutes per session whereas TBS is complete in as little as 3-5 minutes. In the “THREE-D” randomized control trial, iTBS has proven to be similar to traditional TMS in regards to effectiveness, safety, and tolerability.
How do I schedule an appointment with the UNC TSM Clinic?
We ask that you work with your doctor to complete our New Patient Intake Packet in-full and mail or fax to our intake coordinators PRIOR to scheduling your TMS consultation appointment. This information will allow us to have a more meaningful conversation in our initial consultation and determine how we may best cater to your specific needs as a potential TMS candidate. Prospective patients will then meet with a TMS provider in our outpatient office for an initial consultation to discuss your psychiatric history, determine appropriateness for TMS treatment, and to learn more about our TMS clinic.
Is TMS covered under my insurance?
TMS is not currently covered under UNC Charity Care or Medicaid. Theta Burst Stimulation is currently not covered by most insurances. Medicare and many private insurances do cover TMS specifically for Major Depressive Disorder. Insurance companies that provide reimbursement for TMS generally require a recent (within the last 6 months to 1 year) failed trial of evidence-based individual psychotherapy (CBT, DBT, ACT, interpersonal, etc.) as well as four prior medication trials of adequate dose and duration (usually 6 weeks or more) or with evidence of intolerable adverse side effects. Most insurances will require you to engage in a TMS Consultation with one of our psychiatrists to determine your appropriateness and eligibility for TMS at which point we then work with our pre-arrival team to complete a prior authorization form with your insurance.
What if my insurance will not cover theta burst stimulation or TMS?
There are several reasons why your insurance may not cover TMS; including inadequate medication trials, no recent therapy, or not meeting criteria for Major Depressive Disorder. In this case, we still recommend you talk with our TMS psychiatrist to discuss the risks and benefits of proceeding with TMS. If you choose to proceed, we offer TMS services still on cash basis. We strongly recommend that you reach out to our psychiatry financial coordinator, Sarah Cooper, at 984-974-3931 if you have questions about cost or insurance coverage prior to engaging in TMS.
How long has TMS been researched in studies before getting FDA approval?
The first studies of daily left prefrontal TMS for depression date back to the mid-1990’s at the National Institutes of Health (NIH) in Washington, DC. The technology has been investigated with millions of patients in the US and abroad. There are several meta-analyses that summarize the outcomes and in most cases these ‘pooled analyses’ of the studies have found TMS to be more beneficial than sham (or fake treatment) in relieving depressive symptoms in largely treatment resistant patients who failed more than one antidepressant drug therapy in their current depressive episode.
What TMS devices are FDA approved?
There are currently 7 different TMS devices that are FDA-approved for the treatment of Major Depressive Disorder, and one TMS device that is FDA-approved for the treatment of Obsessive-Compulsive Disorder (BrainsWay Deep TMS). UNC has owned and operated NeuroStar and MagVenture TMS devices for clinical and research use. We currently use the MagVenture MagPro X100 for clinical use in our outpatient clinics.
How effective is TMS on seriously depressed patients?
The severity of depression is assessed in various ways. The most common is to examine the depressive symptoms experienced by a patient at the time of their evaluation. This is done with objective self-administered ratings (PHQ-9, BID, GAD7, and WHODAS) as well as reviewing all medications and psychotherapy that the patient may have undergone in their current depressive episode and in their lifetime to assess how resistant they are to conventional therapy. Although the severity of symptoms in the current depressive episode does not predict worse outcomes, it is generally believed higher treatment resistance and more failed conventional treatments in the current depressive episode may negatively influence the benefits received from TMS. That is, TMS is less likely to work in people who have been ill for many, many years, or who have tried and failed almost all other options. With that said, each person is different and even if you feel you have exhausted all options, you may actually be only ‘treatment resistant’ compared to the patients who have participated in prior TMS research studies. You should talk with your referring doctors and the UNC staff about your specific likelihood of responding and your risk of any potential side effects.
Are there patients that don’t respond to TMS?
Unfortunately, yes. TMS is not a guaranteed cure, and it does not get rid of symptoms in everyone. All available treatments in psychiatry work for some, but not all, patients. TMS is not an exception. Studies have shown that psychotic depressed patients, patients who have failed a course of ECT, and patients with severe comorbid mental disorders like schizophrenia, post-traumatic stress disorder or panic disorder generally do not benefit from the traditional depression TMS protocol. Each case needs to be assessed individually.
What are the side effects of TMS?
TMS involves alternating high magnetic energy to stimulate the brain service. With any brain stimulation technology, there is a risk of inducing a seizure. TMS related seizures have been reported in less than 500 cases of the millions of TMS sessions that have occurred to date. The stimulation parameters used in the study reviewed by the FDA did not cause any seizures. Other side effects include minor headaches, pain at the site of the simulation (forehead/scalp), and mild muscle twitching in the face during treatment delivery. These symptoms greatly improve within a week of treatment and only a handful of patients have stopped treatment because they could not tolerate side effects. Note, but unlike electroconvulsive therapy (ECT), there is no memory loss or confusion associated with TMS treatments. The TMS device can be loud so we do recommend that you wear earplugs or use a music player during your session. Please alert the UNC staff if you have a hearing aid or have prior hearing problems.
Can TMS make my symptoms worse?
TMS may not work for everyone. There is a risk that clinical symptoms of depression would worsen if they are not adequately treated. In some patients, particularly those with underlying bipolar disorder or severe anxiety, TMS can be overly stimulating to the brain and induce worsening anxiety, panic, or insomnia. The clinicians at UNC will be assessing your progress each treatment day and obtaining mood rating scores once weekly to closely monitor for these symptoms.
Can I continue to take my medication while I receive TMS?
They clinicians will carefully review your treatment regimen and work with you to help optimize your treatment and reduce any risks associated with psychiatric medications. In general, you can continue to take your regular medications during your TMS series. However, some medications may need to be stopped or reduced prior to initiating TMS to avoid the risk of seizure.
How long will the benefit of TMD last if I respond?
TMS is a durable treatment for depression with sustained responder rates of 50% up to 1 year after a successful induction course of treatment. All known antidepressant treatments require a maintenance regimen to sustain initial responses. TMS also follows this general rule. The research on TMS as a maintenance therapy is very limited. After your initial TMS series and a short TMS taper, you will be advised to monitor symptoms closely with your primary psychiatrist and therapist to evaluate for any worsening mood. If you and your providers determine that maintenance TMS is warranted, we will work with you on creating a maintenance schedule that meets your needs.
What if TMS does not work for me?
The TMS conditions will work with you and your referring providers to choose the next best treatment for you. The clinic may also provide you with some leads on ongoing clinical research that may also be helpful.
How do I contact UNC TMS Clinic to learn more?
Feel free to call our TMS Coordinator at 984- 974-3983 if you have questions about our services or providers.
UNC TMS Clinic Team
Rachel Frische, MD
Robert McClure, MD
Michael Hill, MD
Shahzad Ali, MD
Sonya Bynum, CMA/ TMS Coordinator (Phone: 984-974-3983, Fax: 984-974-9646)
Sarah Cooper, Financial Counselor (Phone: 984-974-3931)